LSHSS
Tutorial
Tutorial: Speech Motor Chaining
Treatment for School-Age Children
With Speech Sound Disorders
Jonathan L. Preston,a Megan C. Leece,a and Jaclyn Stortoa
Purpose: Operationalized treatments for school-age
children with speech sound disorders may result in more
replicable and evidence-based interventions. This tutorial
describes Speech Motor Chaining (SMC) procedures,
which are designed to build complex speech around core
movements by incorporating several principles of motor
learning. The procedures systematically manipulate factors
such as feedback type and frequency, practice variability,
and stimulus complexity based on the child’s performance.
Method: The rationale and procedures for SMC are described.
Examples are presented of how to design stimuli, deliver
feedback, and adapt the approach. Free resources are
provided to guide clinicians through implementation of
S
peech sound disorder (SSD) involves impaired pro-
duction of speech sounds in relation to a person’s
age and language experience. In school-age children
with persisting SSD, motor-based treatments requiring re-
peated practice of speech targets are common (Hitchcock
& McAllister Byun, 2015; Murray, McCabe, & Ballard,
2012; Shriberg & Kwiatkowski, 1982). Such drill-based
approaches may be appropriate to address speech errors
in school-age children with SSD, including those with ar-
ticulation disorders and childhood apraxia of speech. A
common basis in these subtypes of SSD is impairment at
some level of speech motor function (i.e., articulatory spec-
ifications for a specific phoneme, or planning and pro-
gramming of speech movement sequences). Importantly,
the application of motor learning theories to the treat-
ment of motor-based SSDs suggests that attention to par-
ticular principles may be warranted (e.g., Hitchcock &
a
Department of Communication Sciences and Disorders,
Syracuse University, NY
Correspondence to Jonathan Preston: jopresto@syr.edu
Editor-in-Chief: Shelley Gray
Editor: Ignatius Nip
Received July 19, 2018
Revision received October 2, 2018
Accepted October 16, 2018
https://doi.org/10.1044/2018_LSHSS-18-0081
Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019 • Copyright © 2019 American Speech-Language-Hearing Association
the procedure. Data on fidelity of implementation and
dose per session are presented. Clinical and research evidence
is provided to illustrate likely outcomes with the procedure.
Results: SMC is a method that can result in successful
acquisition of target speech patterns and generalization to
untrained words. Most clinicians can implement the procedure
with over 90% fidelity, and most children can achieve over
200 trials per session.
Conclusion: Clinicians and researchers can use or adapt
the operationally defined SMC procedures to incorporate
several principles of motor learning into treatment for
school-age children with speech sound disorders.
Supplemental Material: https://osf.io/5jmf9/
McAllister Byun, 2015; Maas et al., 2008). However, it can
be a complex task to structure treatment in a manner that
purposefully manipulates numerous aspects of practice and
feedback according to principles of motor learning. The
purpose of this tutorial is to provide a description of Speech
Motor Chaining (SMC), one type of structured motor-
based speech sound treatment utilized in both research and
clinical practice with school-age children with SSD. The
tutorial presents an overview of the evidence base, the the-
oretical rationale, and a description of the procedures for
SMC so that clinicians and clinical researchers may use
and adapt the framework to fit a variety of treatment
needs. Data on treatment fidelity and dose are also sum-
marized, and a freely available data sheet with stimuli is
provided to guide clinicians to implement the procedure.
Research Evidence for SMC
SMC procedures have been applied in a number of
case studies and single-subject experimental designs (Preston
& Leaman, 2014; Preston, Leece, & Maas, 2016, 2017;
Preston, Leece, McNamara, & Maas, 2017; Preston,
Maas, Whittle, Leece, & McCabe, 2016; Preston et al.,
2014; Sjolie, Leece, & Preston, 2016). SMC has been
used as part of treatment with children, adolescents, and
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
343
adults with residual speech sound errors; children with
apraxia of speech; and adults with acquired apraxia of
speech. These procedures can be used both with and
without biofeedback (e.g., Mental et al., 2016; Preston,
Leece, & Maas, 2017; Preston et al., 2014; Vick, Mental,
Carey, & Lee, 2017). Although the procedures were ini-
tially developed to provide a standardized practice structure
as part of a series of studies that included biofeedback
during sound production training, the SMC procedures
are used in each session during periods of practice with-
out biofeedback as well.
Figure 1 presents individual data from six different
case series and single-subject experimental designs that have
included 39 children of ages 8–21 years who were treated
for residual speech errors, primarily on /ɹ/ (Preston, Leece,
et al., 2016; Preston, Leece, & Maas, 2017; Preston, Leece,
McNamara, et al., 2017; Preston, Maas, et al., 2016;
Preston et al., 2014; Sjolie et al., 2016). Most of these chil-
dren had received prior intervention that had not success-
fully remediated all of their sound errors. The mean
pretreatment accuracy for sounds selected for treatment
was 12.4% (SD = 14.5), and the mean posttreatment accu-
racy was 50.2% (SD = 32.1). However, these studies vary
somewhat in the exact characteristics of the participants
(some had childhood apraxia of speech with numerous
sound errors, some had residual /ɹ/ distortions only) and
in the features of the treatment (i.e., the number of hours
of treatment ranged from 14 to 16, the distribution of ses-
sions ranged from 1 to 7 weeks, and the amount of biofeed-
back varied from approximately 20% to 45% of the session).
Figure 1. Target sound accuracy on untreated words for 39 children
whose treatment included Speech Motor Chaining. Each line
represents a separate participant.
344 Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019
To offer an example of more homogeneous sample,
Figure 2 provides data on accuracy of /ɹ/ in untrained
words for children whose treatment included only SMC
with no biofeedback. Accuracy is averaged across six
children of ages 10–16 years with residual speech errors
affecting /ɹ/ who participated in seven 1-hr treatment ses-
sions scheduled twice per week. The average data are from
a single-subject design described by Preston, Leece, and
Maas (2017). Although there was individual variation in
response to the treatment, the data suggest that the average
improvement on untreated items was approximately 33%
from pretreatment to immediately after the 7 hr of therapy.
Moreover, continued monitoring for 5 weeks after with-
drawal of SMC treatment suggested ongoing improvement,
which is evidence of motor learning. Although more than
7 hr of therapy may be required, this provides evidence
that residual speech errors can improve with this motor-
based approach.
Background and Theoretical Motivation for SMC
Although the primary aim of this tutorial is to describe
the SMC procedures, we begin with a brief rationale. Per-
sisting SSD can often be characterized as involving incor-
rect articulatory movements—that is, articulator positions
and transitions between positions, which result in erred
productions of speech sounds. Persisting SSD in school-age
children can be the consequence of a history of speech
delay, a history of normal speech sound development but
failure to achieve accurate production of one or two par-
ticular speech sounds, or a history of motor speech im-
pairment (e.g., Shriberg et al., 2010, 2017). Under the
assumption that the goals of accurate speech sound pro-
duction involve an acoustic target and general movement
goals (e.g., Tourville & Guenther, 2011), the SMC proce-
dures involve training speech movement patterns with feed-
back about both the acoustic quality of speech sounds
and the articulatory actions. The procedures are intended
to address isolated speech sound errors and errors associ-
ated with symptoms of impaired transitions between sounds
and syllables. Therefore, the procedures have been imple-
mented both with children with residual speech sound errors
and children with persisting errors associated with child-
hood apraxia of speech.
Several principles derived from nonspeech motor
learning literature may be relevant to speech motor learn-
ing. Critically, these principles, primarily derived from a
schema-based motor learning theory, define a difference
between instructional parameters that best enhance skill
acquisition versus skill learning (Maas et al., 2008; Schmidt
& Lee, 2011). Skill acquisition refers to increased perfor-
mance during practice. In the context of speech therapy,
acquisition may reflect temporary improvement in speech
sound accuracy while practicing within a session. Conversely,
skill learning refers to relatively permanent changes, includ-
ing retention and generalization of the skill to untrained
tasks. Thus, some clients show acquisition of correct artic-
ulatory patterns (improved accuracy during sessions) but
 Figure 2. Mean accuracy on word-level generalization probe for six children with /ɹ/ distortion. B = baseline
(pretreatment); P = posttreatment; 2M = 2 months follow-up. Error bars represent standard deviation.
Treatment occurred for seven sessions (dashed box).
fail to demonstrate learning (i.e., poor generalization or reten-
tion). In the context of therapy for SSD, early stages of
treatment may require initial emphasis on skill acquisition
to establish the core movements; however, a plan for sys-
tematic transition to skill learning is essential.
Maas et al. (2008) outlined several key aspects of
practice and feedback, which are believed to influence skill
acquisition and learning. For example, with respect to the
complexity of targets, practice with simple targets (e.g.,
syllables) is expected to yield high performance during ac-
quisition, whereas practice on complex targets (e.g., sen-
tences) is more likely to facilitate skill learning. In addition,
constant practice (e.g., minimal variation in consonants,
vowels, and prosodic content) should enable skill acquisi-
tion, but variable practice (e.g., increasing stimulus set size
and varying prosody) should enhance learning. The prac-
tice schedule may also play a role, such that blocked prac-
tice (e.g., many consecutive repetitions of the same target)
leads to skill acquisition whereas random practice (e.g.,
mixing up stimuli) facilitates motor learning. Moreover,
with respect to the feedback that is provided to the learner,
knowledge of performance (KP) feedback (e.g., detailed
feedback about movements, such as “the sides of your ton-
gue were down too low for /s/”) may lead to skill acquisi-
tion, but less specific feedback or knowledge of results
(KR; e.g., information about correctness, such as “good /s/
sound”) should facilitate motor learning. Skill acquisition
is expected to increase when frequent feedback is provided
to the learner, but learning may be facilitated by less fre-
quent external feedback. Finally, immediate feedback is
hypothesized to enhance skill acquisition, but a brief delay
before feedback is provided may facilitate motor learning.
Several of these principles are embedded within SMC
treatment.
Individuals with SSD may require scaffolded support
to achieve the goal of consistent production of articulatory
movements that result in acoustically acceptable productions
of phonemes. The support provided by clinicians should
change over time in order to optimize learning. The SMC
treatment described here involves an initial emphasis on
acquisition to elicit and establish speech sounds, followed
by structured steps toward speech motor learning. There-
fore, SMC feedback and practice procedures are designed
to initially facilitate acquisition of simple speech targets
through conditions such as frequent and specific feedback
and constant practice. Based on the learner’s success, the
treatment is dynamically adapted through five levels to ad-
dress increasingly complex stimuli with strategies that in-
clude less frequent and less specific feedback and more
variable practice.
Another guiding principle is the need to practice at
the optimal level of difficulty while offering the appropri-
ate level of support (Guadagnoli & Lee, 2004; Hitchcock
& McAllister Byun, 2015). The assumption is that, to max-
imize motor learning, learners must be appropriately
challenged based on the task demands and the available
information (e.g., cues, feedback). Therefore, many tradi-
tional hierarchies of articulation therapy require learners to
achieve a predetermined accuracy within a session (e.g., 85%
accuracy on /ɹ/ at the syllable level) prior to advancing to
a more complex task (e.g., /ɹ/ at the word level). However,
the SMC procedures are designed to adapt more quickly as
the learner is successful, with changes in the task occurring
after every six trials. Thus, for children who are successful, it
is possible to practice syllables, words, phrases, and sen-
tences all within the course of approximately 2 min. For
children who are unsuccessful in their productions, practice
can remain at the syllable level for an entire session. This
frequent decision making enables more flexibility than some
traditional approaches in which modifications to linguistic
level (e.g., syllables vs. words) or clinician support (e.g.,
amount of feedback) occur only between sessions.
Finally, the SMC procedures described herein involve
stimuli that are chained. The general purpose of chaining is
to quickly build to complex speech movements (i.e., words
and phrases) around previously trained smaller units (i.e.,
sound sequences embedded in syllables). Chaining has been
described for many years in the speech disorder literature
as a way to teach appropriate coarticulation between sounds,
to produce appropriate allophonic variation, and to main-
tain syllabic integrity through the smooth transitioning
among syllables (Chappell, 1973; Johnson & Hood, 1988;
Preston et al.: Speech Motor Chaining 345
Young, 1987). The SMC procedures described here are an
attempt to operationalize a form of chaining for the pur-
poses of clinical practice and clinical research (though
other formalisms could be developed). The procedures in-
volve the selection of a target sound in syllable position
(e.g., /k/ in onset or /s/ in coda). Sound sequences (CV,
VC, or CC) are chosen, which represent the target sound
in syllable position. The selection of a sound sequence as
the unit of training is motivated by the literature attesting
to notion that the units of speech planning extend beyond
individual phonemes (e.g., Bohland, Bullock, & Guenther,
2010; Redford, 2015; Tilsen, 2013). During practice, addi-
tional movements are gradually added before the target
sequence (backward chaining) or after the target sequence
(forward chaining). For example, when training the target
/k/ in onset, one representative sound sequence is /kl/.
Chaining for each sequence begins in a syllable (e.g., /kle/),
followed by a monosyllabic word (e.g., claim), a multisyl-
labic word (e.g., proclaim or claiming), a short phrase (e.g.,
proclaim the news, or He wasn’t claiming), and eventually a
self-generated sentence (e.g., using the word proclaim or
claiming in a sentence). Practice at the higher levels of lin-
guistic complexity only occurs when there is success at the
previous level. Within each level, however, the feedback
provided to the learner addresses the target movement se-
quence (/kl/). Thus, there is an intentional plan for building
complexity around each stimulus that is chosen, as the
larger units (e.g., multisyllabic words) are designed to en-
compass the smaller units (e.g., monosyllabic words and
syllables) to facilitate success.
Assessment Considerations
and Treatment Planning
Treatment can be planned appropriately following a
thorough assessment. In addition to a standardized assess-
ment of speech sound production to verify the presence of a
SSD, deep testing is particularly helpful when using SMC.
Deep testing involves assessing a speech sound across a va-
riety of words sampling various phonetic contexts, including
different word positions, stress patterns, and adjacent pho-
nemes (Kent, 1982). Finding prosodic environments and
coarticulatory contexts in which the child is most successful
can assist in selecting initial stimuli for SMC sessions. For
example, for a child whose /ɹ/ in coda position is correct
only 10% of the time, noting that the correct production
occurs following a back vowel /ɑ/ may encourage the selec-
tion of /ɑɹ/ as one target syllable to practice in treatment,
which may facilitate acquisition of /ɹ/ in other contexts.
Appropriate targets for SMC are typically sounds
that are below 50% accuracy in a particular syllable posi-
tion when tested at the word level. Typically, two broad
targets are treated per child for each session (e.g., onset /ɹ/
and coda /k/). Following the selection of sounds in word
position targets, four variants (i.e., sound sequences) are
initially chosen. Variants of the target are two-phoneme (e.g.
CC, CV, VC) or occasionally three-phoneme (e.g., CCC)
346 Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019
sequences. For example, the target of onset /ɹ/ could be ad-
dressed with four variants: two /ɹ/ singleton variants such
as /ɹi/ and /ɹɑ/ and two /ɹ/ cluster variants such as /dɹ-/ and
/kɹ-/. Coda /k/ could be addressed with four variants such
as singletons /ek/ and /ʊk/ and clusters /-kt/ and /-sk/. In each
session, two different chains are chosen per variant, resulting
in 16 chains per session (2 sounds × 4 variants × 2 chains).
This choice of sound sequences as treatment targets (rather
than isolated sounds) demands intentional focus on a move-
ment pattern (such as a consonant transitioning into or out
of various vowels), rather than simply production of a
phoneme. In selecting these sequences, a relative range of dif-
ficulty could be considered based on the client’s observed
success during an assessment; for example, some variants
may include sequences that are likely to be facilitative, and
some variants may include sequences that are likely to be
more challenging. Chains are then built around the chosen
variants.
Phonetic context should be considered when selecting
phoneme sequences that represent the target sound in word
position. If a client is minimally stimulable in one phonetic
context, it is important to try to practice that facilitative
context in at least one chain to allow the client to experience
some success in a session. If the client is not stimulable in
any context, syllables can be chosen, which theoretically
may be phonetically facilitative (e.g., /ɑɹ/ may be potentially
facilitative for /ɹ/ because /ɑ/ promotes pharyngeal constric-
tion; /ts/ may be facilitative for /s/ due to the presence of a
preceding alveolar stop; /ʊk/ may be facilitative for /k/ due
to the presence of the mid–high back vowel). When possible,
the chosen sound sequences should sample a variety of pho-
netic environments to encourage accurate production of
movement gestures across various coarticulatory contexts.
Thus, when selecting vowel contexts to be paired with a
consonant, nonadjacent vowels along the vowel quadrilat-
eral should be considered. For example, variants to address
/ɹ/ in onset may include /ɹi/ and /ɹɑ/, because of the high-
front and low-back vowels (vis-à-vis /ɹi/ and /ɹɪ/, which are
closer on the vowel quadrilateral). Similarly, choosing con-
sonant clusters that vary in place of articulation allows
for practice across various coarticulatory environments
(e.g., /dɹ-/ and /ʃɹ-/ may be preferred variants because they
differ in place of articulation, manner, and voicing of the
first phoneme, vis-à-vis /dɹ/ and /tɹ/, which differ only in
voicing). Practicing such variation may facilitate acquisi-
tion of contextually driven allophones (cf. Mielke, Baker,
& Archangeli, 2016). Table 1 provides examples of target
sequence selection that encourages varied phonetic contexts.
Supplemental Material S1 provides further examples of
how chains are built around the selected variants.
Prepractice
Typically, SMC sessions are initially divided into two
phases: prepractice (elicitation) and structured practice using
SMC. Later, a third phase, randomized practice, may be
added. Within the prepractice phase, the clinician helps the
learner to identify a minimum reference for correctness
Table 1. Examples of target sound/position and four possible variants
(sound sequences) for practice across a range of phonetic contexts.
Target sound/position Variant 1 Variant 2 Variant 3 Variant 4
/ɹ/ onset /ɹɑ/ /ɹi/ /dɹ/ /kɹ/
/s/ onset /si/ /so/ /sk/ /sn/
/k/ rhyme /ɪk/ /æk/ /sk/ /kt/
/ʧ/ rhyme /iʧ/ /æʧ/ /ʌʧ/ /nʧ/
such that the child becomes familiar with the distinction
between correct and incorrect productions of the variants.
Stimulability for the chosen variants is achieved with model-
ing, shaping, and verbal and visual cues for articulator
placement and movement (e.g., Secord, Boyce, Donohue,
Fox, & Shine, 2007). For example, to address /ɹ/, shaping
strategies may involve /l/→/ɹ/ or /ɑ/→/ɹ/. However, trials
within prepractice are not considered successful until the
entire sound sequence is produced correctly (e.g., correct
production of the syllables /ɹi/ or /ɹɑ/ with smooth transitions
between segments, not just isolated /ɹ/). Phonetic placement
for /ɹ/, for example, may consist of cues to elevate the ante-
rior tongue, keep the dorsum low, elevate the sides of the
tongue, retract the tongue root, or keep the lips steady.
Visual cues to aid the prepractice stage may include images
of vocal tract shape (e.g., http://www.seeingspeech.ac.uk/
ipachart/) or tongue–palate contact with electropalatography
examples (e.g., McLeod & Singh, 2009). Within the pre-
practice phase, the clinician provides frequent cueing and
immediate detailed feedback to elicit correct productions
from the client. In our approach, prepractice is continued
until the client achieves several correct productions of each
variant (at least three correct productions of each variant).
During the prepractice phase, the clinician can determine
the phonetic cues that are most valuable in helping the child
achieve correct productions, and such cues may be continued
during the feedback that is provided during structured
practice with SMC.
SMC
After a sufficient number of correct productions of
each variant are achieved during prepractice, practice with
SMC begins. The SMC data sheet is designed to guide
clinicians through the implementation of the following prin-
ciples. Target syllables, words, and phrases are elicited in
blocks of six consecutive attempts, and practice starts at
the syllable level. Some example chains are shown in Table 2.
Chains consist of five practice levels, which are defined by
complexity around the target variants:
1. syllables, which contain at least one consonant and
one vowel: CV, CC(V), VC, or (V)CC—these are the
basic sound sequences (variants) representing the target;
2. monosyllabic words, which begin or end with the syl-
lable and which contain both an onset and a coda;
3. multisyllabic words, which include two or more syl-
lables and which contain the monosyllabic word;
4. phrases, which include two to five words and which
contain the monosyllabic word or the multisyllabic
word; and
5. self-generated sentences, in which the child uses either
the monosyllabic word or multisyllabic word in a
novel sentence.
Advancing from one level of a chain to the next level
requires at least five of six correct productions in a block.
For example, five correct productions of the syllable /ɹɑ/
are needed to progress to the monosyllabic word rock.
Failure to achieve at least five correct productions at any
level results in moving to a new chain with a different vari-
ant of the target, returning to Level 1 (e.g., switching from
a /ɹɑ/ chain to a /ɹi/ chain). In the current operationalized
structure, a chain is mastered when a child successfully pro-
gresses through all five levels of the chain on two separate
occasions (i.e., at least five correct productions of a self-
generated sentence). Once the chain is mastered, a replace-
ment chain with the same variant is used in the next ses-
sion (e.g., replace rock-rocket-my rocket ship with a chain
such as rot-rotten-rotten food ).
The SMC structure enables the client to quickly
practice up to a level that is sufficiently challenging, similar
to the “challenge point” framework (Guadagnoli & Lee,
2004; Hitchcock & McAllister Byun, 2015; Rvachew &
Brosseau-Lapré, 2012). That is, clients work at a level of
difficulty in which some but not all attempted utterances
are likely to be correct. If the task proves too hard, practice
returns to the syllable level again in conditions that are more
acquisition focused (limited linguistic level/less complex,
frequent and specific feedback) before building up to tar-
gets that are more learning focused (higher linguistic levels,
more variability, reduced feedback).
Feedback
Verbal feedback by the clinician on any trial during
SMC consists of KR, KP, or no feedback. Table 3 pro-
vides examples of clinician responses for these types of
feedback.
KR refers to information only about the correctness
of the speech sounds (phonetically correct or incorrect).
That is, the acoustic accuracy is judged as either being a
good (accurate) or poor (inaccurate) form of the target
sounds. KR feedback is typically associated with motor
learning because the clinician offers no specific information
about why a production was correct or incorrect or what
movements the client should change (Maas et al., 2008).
KP refers to feedback about the nature of the move-
ment that was just performed. If a sound is produced in
error, the KP feedback provided by the clinician should
make reference to aspects of the phonetic placement, vocal
tract configuration, or movement sequencing that need to
change to achieve a correct production. If a target sound is
produced correctly, the KP feedback should highlight as-
pects of the movement that resulted in correct production.
The KP feedback is therefore specific to the type of error
produced or the movement that was achieved. The KP
Preston et al.: Speech Motor Chaining 347
Table 2. Examples of chains.

Sound/position Syllable Monosyllabic word Multisyllabic word Phrase Self-generated sentence

/ɹ/ onset /ɹɑ/ rot rotten rotten food ?

/ɹ/ rhyme /ɔɹ/ for before just before ?
/k/ onset /ki/ keep keeping keeping my money ?
/k/ rhyme /ʊk/ book bookshelf on the bookshelf ?
/s/ onset /sɪ/ sit sitting sitting down ?
/s/ rhyme /æst/ cast broadcast national broadcast ?
/ʧ/ onset /ʧæ/ champ champion world champion ?
/ʧ/ rhyme /ɪʧ/ witch sandwich eat a sandwich ?

Note. Observe that the target sequence (in bold) remains consistent throughout the chain.

feedback typically aids acquisition and is provided fre-
quently in the early stages of treatment because the clini-
cian offers specific information to the client about the
essential aspects needed to achieve the intended speech
movements. In SMC, the KP feedback is provided on
four of six trials at the syllable level and on one of six trials
at the sentence level. Generally, when the KP feedback is
provided, it is implicitly or explicitly accompanied by the
KR feedback as well. For example, “Good job [KR]! You
lifted the back of your tongue up [KP] when you started
/ki/.” In several previous studies, periods of treatment ses-
sions have included verbal KP supplemented with visual
KP in the form of visual biofeedback (e.g., Preston & Leece,
2017; Preston, Leece, et al., 2016; Preston et al., 2014).
The amount and type of feedback at each level is
intended to change as client’s progress in SMC, with
successive reductions in the amount of feedback (i.e.,
fewer trials with feedback) and changes in the type of
feedback from primarily KP to primarily KR. The type
of feedback assigned to a trial is specified on the SMC
data sheet.
SMC Data Sheet
A data sheet is available to guide users to implement
the SMC procedures. A sample data sheet is available in
the Appendix. A fillable electronic copy in Microsoft Excel
is freely available at https://osf.io/5jmf9/, which can be used
with a computer or a tablet (see Supplemental Material S1).
A number of prepopulated chains are included in the file
(accessible as drop-down selection choices), although new
chains can be added by users.
At the top of the data sheet, the target sound/word
position is entered along with four variants. Also, along

Table 3. Examples of knowledge of results and knowledge of performance feedback.

Feedback type Segments Positive feedback Negative feedback

Knowledge of results Any Correct. Not that time.

Knowledge of performance
Knowledge of performance
Knowledge of performance
You got it. No.
Great. Didn’t get that one.
Excellent. Not that one.
Way to go. Not quite.
/ɹ/ Good, your tongue tip was raised. Not quite. Lift the front of your tongue
up a little.
Got it! Your sides were up. Not quite. Try to lift the sides up to touch
the back molars.
Yes, you got tongue root back into the throat. Not that time, try to pull the tongue root
back into the throat.
Good, you kept the back of your tongue down. No, I think you raised the tongue dorsum
too high.
Good, you kept the lips steady. Not quite. Your lips were sticking out
too much.
/k/ Awesome! You kept your tongue tip down. No. Both the tongue tip and the tongue
dorsum were up on that one.
Good, you raised the back of your tongue. Not quite. You raised the tip up, not the
dorsum.
Great job lifting the dorsum up. Didn’t get the dorsum up to the roof of
your mouth.
/s/ Got it. The sides of the tongue were touching Not quite. The middle and sides were even.
your teeth.
I like that you made a nice deep groove. Not that time. The groove wasn’t there.
Great job keeping the air moving the No. The air stopped and didn’t move through
whole time. the whole /s/ sound.

348 Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019
the top is a section to track the number of correct produc-
tions during prepractice.
The remainder of the data sheet displays the list of
chains chosen for practice during the session. The client’s
performance is assessed by the clinician after every six tri-
als to determine whether practice should build to a more
complex stimulus (moving to the right on the data sheet)
or whether practice should switch to a chain for a different
variant (moving down on the data sheet). The criterion of
five correct in a block of six is required to move to more
complex targets in a chain. Thus, each trial should be
scored, and a sum should be computed after each block
of six trials.
The data sheet also provides information to guide
the nature and type of feedback that should be provided
by the clinician. Within each block, feedback in the form
of KR, KP + KR, and no feedback trials are randomly
allocated to the six trials while maintaining the expected
proportion (e.g., at the syllable level, one trial with no
feedback, one trial with KR feedback, and four trials
with KP + KR feedback, but at the sentence level, there
are three trials with no feedback, one trial with KR + KP
feedback, and two trials with KR feedback).
Prosodic Variation
Practice variability can be included in the form of
prosodic variation. This is intended to encourage practice
of the target sound sequences in utterances that vary in
rate, intonation, or loudness. When prosodic variation is
included, clients are cued to practice utterances slow, fast,
loud, as a question, as a command, or as a statement. Al-
though this variation was found to have a minimal impact
on speech sound learning in children with residual speech
sound errors (Preston et al., 2014), recent research with
children with childhood apraxia of speech has suggested
that this prosodic variation may aid generalization and
retention in that population (Preston, Leece, McNamara,
et al., 2017). Thus, prosodic variation may help children
learn to integrate articulatory movements with other param-
eters of speech that are planned.
Self-Monitoring
Another feature of SMC includes explicit require-
ments for clients to self-rate the accuracy of their produc-
tions. In our current version of SMC, each block of six
trials requires self-rating on three trials. Before any feed-
back is given by the clinician, the child is asked to pro-
vide a self-evaluation of accuracy. Such procedures have
been shown to facilitate generalization in speech sound
learning (Koegel, Koegel, & Ingham, 1986; Ruscello &
Shelton, 1979). After the child self-evaluates, the clinician
may provide feedback by stating whether they agree or
disagree with the child’s judgment.
A sample chain including prosodic cues and self-
monitoring is provided in the Appendix. In addition, a video
example of portion of a session using SMC is provided in
Supplemental Material S2.
Increasing Difficulty of Chains
Intentional modifications to the chains selected for
treatment may influence task difficulty. Initially, chains are
chosen which place the target sound sequence in a facilita-
tive context in word-initial or word-final position, and
chains include the target sound in a stressed syllable in mul-
tisyllabic words. However, over the course of treatment,
chains that are mastered (i.e., produced correctly through
the sentence level on multiple occasions) need not be re-
peated but instead can be replaced by chains that may be
more challenging to the speech system. Three strategies
for increasing the difficulty of chains are discussed below.
The properties of the chains differ starting at the mono-
syllabic or multisyllabic word level. Examples of these
modifications are shown in Table 4.
Word-Medial Position
When targeting a sound sequence in word-initial or
word-final position, there is only one coarticulatory transi-
tion that must be practiced (i.e., transitioning into or out
of the target movement sequence, but not both, as in /kle/
at beginning of claiming). Positioning the target sound se-
quence in medial position of multisyllabic words creates a
potentially more challenging coarticulatory environment,
requiring smooth transitions into and out of the target
movement pattern (e.g., /kle/ in proclaim). This change may
increase the demands on motor planning as the sequences
are embedded in a larger stream of movements. Often, word-
medial chains are introduced with the addition of a bound
morpheme (prefix or suffix), although compound word
contexts (e.g., two-syllable spondees) can be used as well.
Lexical Stress
To increase the difficulty of planning multisyllabic
words, the target sequences can also be practiced in syl-
lables that do not carry primary stress. Often, targets in
syllables with primary stress (e.g., /ɹi/ in reading) are
more accurate because they are typically longer in dura-
tion than syllables that do not carry primary stress (e.g.,
/ɹi/ in realistic); thus, stressed syllables may reduce the
demands on motor programming. In unstressed syllables,
however, the target sequences may be more challenging
to the client because there is less time to plan and exe-
cute movements and less transition time between articu-
latory gestures.
Competing Sounds
To increase the difficulty of chains, competing sounds
may be included. Competing sounds are those that share
some articulatory gestures with the target (typically manner
or place of articulation of consonants). Competing sounds
may also include the child’s typical error for a sound and
may be present in the same word or in another word in a
phrase. Competing sounds challenge the speech planning
Preston et al.: Speech Motor Chaining 349
Table 4. Strategies to increase the difficulty of chains.
Monosyllabic “Basic” speech
Variant word motor chain
/ɑɹ/ tar guitar
/ɑk/ lock unlock
/se/ sale sailor
Note. Observe that the target sequence (in bold) remains consistent throughout the chain.
system by intentionally including articulatory gestures,
which may interfere with the intended sound sequences (cf.
Rogers & Storkel, 1998; Tilsen, 2013). For example, com-
peting sounds for /ɹ/ in a target sound sequence may in-
clude /l/ (which is also a liquid) or /w/ (which is also a
semivowel and is a common substitute for /ɹ/). Thus,
words such as Larry and rewind would be target words
with competing sounds for the target sequence /ɹi/. Com-
peting sounds for /k/ in a target sound sequence may in-
clude /ɡ/ or /ŋ/ (which are also velars) or /t/ (which is a
common substitute for /k/). Thus, words such as took and
book bag include competing sounds for the target sound
sequence /ʊk/. The competing sounds strategy can be im-
plemented at the monosyllabic word level; however, it is
recommended that competing sounds be introduced when
the client can readily produce the target sound sequence
in words that do not have a competing sound. Compet-
ing sounds could also include repetition of the target
sound sequence in different syllables or words, as in took
the book.
Randomized Practice
SMC procedures may set the foundation to transi-
tion into more complex tasks. For example, the blocked
practice in SMC may improve acquisition, but randomiza-
tion may aid learning. Therefore, in our recent iteration of
SMC (e.g., Preston & Leece, 2017; Sjolie et al., 2016), a
period of randomized practice has been included at the end
of sessions once a child is capable of progressing through
prepractice quickly (i.e., with zero or one error on syllables).
In the current version of practice sessions, randomized
practice is included in the last 5–8 min of a session using
the highest items on each chain that were produced cor-
rectly during SMC (i.e., items with at least five of six trials
correct). Based on the client’s performance during SMC
earlier in the session, randomized practice items may range
from syllables through sentences. The varied stimulus
items from the chains practiced during the session can then
be shuffled such that the child is unaware of which item is
coming next (cf. Skelton & Hagopian, 2014). To further
incorporate motor learning principles, prosodic variation
is also cued during randomized practice (e.g., say the word
read loudly; say the sentence I found a book as a question),
and delayed KR feedback is provided on only 50% of trials
during randomized practice.
350 Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019
Multisyllabic word options
Medial Lexical Competing sounds
position stress or multiple targets
tarnish starvation rock-star
clockwise hemlock gridlock
assailant wholesale sailboats
Caveats
SMC procedures are designed to facilitate a transition
from acquisition to motor learning. However, SMC may be
supplemented with other clinical procedures. For example,
auditory perception and phonological awareness are relevant
skills that may be related to SSD in school-age children
(e.g., Preston & Edwards, 2007; Shuster, 1998). Therefore,
auditory perceptual training and phonological awareness
may also be targeted in a session to address multiple levels
of representation of speech (Preston & Leece, 2017; Preston,
Leece, et al., 2016; Preston, Leece, McNamara, et al., 2017).
Thus, a comprehensive treatment session may include SMC
supplemented with additional clinical procedures.
In addition, the SMC procedures described here have
been developed over time and should not be viewed as
unchanging. For example, the randomized practice, self-
monitoring, and prosodic variations that are included in
the current iteration of SMC were not all part of the proce-
dure when it was initially developed. Because a number
of parameters have been operationalized, they can con-
tinue to be empirically tested. For example, variations in
the number of items per block, frequency of feedback,
and amount of self-monitoring could all be varied and
tested to maximize efficiency.
Finally, it should be noted that, like all current treat-
ments, SMC may not be appropriate for all children. For
example, we expect that many 3- to 4-year-olds, or older
children with significant intellectual disabilities, may not
respond well to a highly structured drill-based treatment
(though this speculation remains to be empirically tested).
Furthermore, as was evident in Figure 1, many but not all
children show signs of generalization with this treatment.
To date, we have observed acquisition (correct productions
of target sound patterns within treatment sessions) for
nearly every child, but those gains in treatment sessions
do not ubiquitously result in increased performance on
generalization measures. This may be a function of an in-
sufficient number of hours of treatment or a need for a dif-
ferent type of treatment. Therefore, continued refinement
of the procedure remains warranted.
Implementation of SMC Procedures
In addition to the research implementation described
earlier, SMC has been used by a number of certified
speech-language pathologists and student clinicians in the
Gebbie Speech-Language Clinic at Syracuse University.
The procedures have been used with children ages 6 years
through adults with various SSD profiles, including resid-
ual speech errors and childhood apraxia of speech. Although
the primary implementation has been during individual
therapy sessions, the procedures have also been adapted
for group therapy (cf. Skelton & Richard, 2016). For ex-
ample, children in the group may practice a chain one at a
time (from syllable level through the highest level to
which he or she can progress). To encourage generalization
and attention to others’ speech, children in the group can
be taught to attend to others’ productions and to provide
KR feedback to other members of the group (cf. Johnston
& Johnston, 1972). Reinforcers such as a turn-taking game
can be completed with one child while another child be-
gins a new chain.
Typically, in a clinic setting, sessions are scheduled
one to two times per week for an hour, although other service
delivery options are feasible. For example, a more frequent
treatment schedule (e.g., daily sessions) can be considered,
particularly in the early stages of acquisition (cf. Preston &
Leece, 2017). SMC may also be a viable approach for
implementing short individualized drill-based sessions in
school settings (cf. Sacks, Flipsen, & Neils-Strunjas, 2013).
Fidelity
Procedures that are most likely to be adopted clini-
cally are those in which high levels of fidelity can be
achieved. Data from studies that have included five certi-
fied speech-language pathologists and two graduate stu-
dents are listed in Table 5. The clinicians for whom
fidelity data are reported engaged in a one-on-one train-
ing with the first author, with total training lasting approx-
imately 3 hr. This training session consisted of review of
the SMC data sheet, a manual, cueing and feedback
strategies, and audio files of sessions. The fidelity data in
Table 5 represent the proportion of trials in which the treat-
ing clinician provided feedback as specified by the proce-
dures. The mean proportion of trials in which adequate
feedback was provided exceeds 80% for all clinicians, and
it exceeds 90% for all but one clinician. This suggests
Table 5. Fidelity on feedback structure.
Clinician No. of sessions
SLP 1 23
SLP 2 15
SLP 3 12
SLP 4 8 98.0 (1.4)
SLP 5 4 99.1 (0.5)
SLP Student 1 8 96.3 (2.7)
SLP Student 2 4 95.1 (6.6)
Note. SLP = speech-language pathologist.
fidelity on the feedback structure can be achieved even
for student clinicians.
Dose
Studies have shown that a relatively high rate of
practice trials in speech therapy can be beneficial for learn-
ing (e.g., Edeal & Gildersleeve-Neumann, 2011). Figure 3
shows the distribution of the average number of SMC
practice trials per participant across 36 participants of
ages 7–24 years reported in six studies (Preston & Leece,
2017; Preston, Leece, et al., 2016; Preston, Leece, & Maas,
2017; Preston, Leece, McNamara, et al., 2017; Preston,
Maas, et al., 2016; Sjolie et al., 2016). Each participant’s
mean number of trials per session is based on 14–20 treat-
ment sessions that included 40–52 min of time devoted to
speech practice. One quarter of the participants (nine of
the 36) practiced an average of less than 100 trials per ses-
sion, primarily because they required several sessions to
achieve stimulability and therefore had numerous sessions
with zero trials in SMC practice. That is, a lower dose is
generally due to the time spent achieving several successful
productions in prepractice before moving to SMC (rather
than a function of inefficient SMC). Typically, participants
attempt fewer trials in early sessions (when more time is
spent in prepractice and less time is spent in SMC) and in-
creasingly more trials in later sessions (when less time is spent
in prepractice and more time is spent in SMC). Overall,
these participants averaged 218 trials per session (SD = 131),
and the data suggest SMC may be viewed as yielding a
high dose for most participants.
Performance During Acquisition
Versus Generalization
The data collected during SMC are reflective of the
acquisition process, but not the generalization process.
Therefore, generalization data on untreated items, rather
than success during SMC practice trials, should serve as
a primary outcome when monitoring progress. Our practice
to monitor generalization takes approximately 3 min to
administer and includes probing accuracy of the target sound
in word position on a list of 25 untreated monosyllabic
Percent of trials in which prescribed
feedback was provided
M (SD) Range
98.5 (2.2) 84–100
97.0 (1.8) 93–99.4
81.9 (19.2) 41.8–94.5
95.6–100
98.2–99.5
91.7–98.7
86.9–95.24
Preston et al.: Speech Motor Chaining 351
Figure 3. Boxplot representing mean number of Speech Motor
Chaining (SMC) trials per session for 36 participants with speech
sound disorders. Each data point represents mean number of
trials per session across 14–20 sessions.
and multisyllabic words. Items are administered by hav-
ing children read a list of words (or name pictures if reading
skills significantly interfere with the process). Essentially,
any word that is not on the generalization list would be eli-
gible to select for training in SMC. In several previous
studies, generalization probes have been administered after
approximately every two sessions. However, the require-
ments of frequent monitoring in an experimental design
may not be the same as those required clinically; there-
fore, as generalization is a gradual process, probes may be
useful for monitoring progress after approximately every
three to four sessions. We recommend administering probes
at the beginning of a treatment session rather than at the
end, as accuracy at the beginning of the session will reflect
not only generalization but also retention from previous ses-
sions. As performance reaches approximately 80% or higher
on untreated words, probing accuracy in 10–15 untrained
sentences may replace word-level probes. Accuracy above
80% on sentence-level stimuli may be sufficient to discon-
tinue SMC and to then shift focus to treatments that focus
on conversational monitoring.
Case Example
Ryan (pseudonym) was a 10-year-old with normal
language and hearing. He participated in seven 1-hr treatment
sessions to address production of /ɹ/ in onsets. Prior to
treatment, he was not stimulable for /ɹ/ in any contexts.
His treated variants included /ɹæ/ and /ɹi/, with chains such
as rap, rapid, rapid decision and read, redeem, redeeming
quality. In addition to his within-session performance,
progress was tracked every other session on word-level
352 Language, Speech, and Hearing Services in Schools • Vol. 50 • 343–355 • July 2019
generalization probes containing untrained words. Moni-
toring on these probes continued weekly for 5 weeks after
withdrawal of SMC treatment.
The bars in Figure 4 show within-session performance
for Ryan during the seven treatment sessions. In the first
session, he did not reach the criterion to advance to SMC,
and he, therefore, remained in prepractice (i.e., sessions
consisted of strategies such as shaping and phonetic place-
ment cues to elicit /ɹ/ in syllables). However, in Sessions 2
and 3, he progressed from prepractice to SMC where he
was successful in achieving correct productions only at the
syllable level. At Session 4, he began to achieve successful
productions in monosyllabic words; in Session 5, he pro-
duced chains through multisyllabic words and phrases, and
in Sessions 6 and 7, he progressed to chains with sentences.
It can be seen in Figure 4 that the total number of trials
increased greatly as he spent less time in prepractice, be-
came increasingly accurate, and required less feedback
and instruction. Furthermore, SMC resulted in a high rate
of practice with over 350 productions per hour during
Sessions 5–7.
Figure 4 also shows his performance on the generali-
zation probe (solid line) before, during, and after treat-
ment (as rated by three listeners who were blind to when
the recordings were collected). He was perceived to be
below 10% accurate before treatment, and the week after
his SMC sessions ended, he was 66% accurate on /ɹ/ on-
sets. A final follow-up session 2 months later revealed
word-level performance over 90%.
The acquisition data during SMC treatment and the
generalization data in Figure 4 provide complementary
perspectives on his performance. That is, it was only after
seven sessions of treatment that he began to show signs
of generalization to untreated words. It may be that a par-
ticular threshold of accuracy or a cumulative effect of
many correct trials within a session is required before gen-
eralization is observed.
Conclusion
SMC is an operationalized form of speech practice,
which is designed to dynamically transition from an em-
phasis on principles of acquisition to an emphasis on prin-
ciples of motor learning. Speech movement patterns are
gradually expanded, such that larger speech units (e.g.,
multisyllabic words) incorporate the same general move-
ment patterns that were produced successfully in smaller
speech units (e.g., monosyllabic words, which were also
practiced in syllables). Moreover, as motoric and linguistic
complexity expands, variability of practice is added and
feedback type and frequency are manipulated. The proce-
dures involve a rapid rate of practice with the potential for
frequent changes to practice conditions. However, the pro-
cedures can be delivered with high fidelity using a freely
available data sheet, allowing for replicable implementa-
tion. Furthermore, the theoretically motivated framework
allows for systematic study of the key elements (an ongo-
ing process), and modifications of the approach for clinical
 Figure 4. Acquisition data (bars) and generalization data (line) for a 10-year-old with /ɹ/ distortion. Generalization probe
data were collected before, during, and after seven sessions of treatment with Speech Motor Chaining (SMC).
and research endeavors are quite feasible. SMC is therefore
one approach that may be considered for treatment of
SSD in school-age children.
Acknowledgments
The authors thank Patricia McCabe for feedback on early
stages of the development of this approach. Research reported
in this publication was supported by the National Institute on
Deafness and Other Communication Disorders under Awards
R15DC016426 and R03DC012152 (J. Preston, PI). The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health.
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Speech Motor Chaining Data Sheet

Preston et al.: Speech Motor Chaining 355